Provider Demographics
NPI:1528031804
Name:WATSON, EDWARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:J
Last Name:WATSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4614
Mailing Address - Country:US
Mailing Address - Phone:860-443-4148
Mailing Address - Fax:860-442-3805
Practice Address - Street 1:471 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4614
Practice Address - Country:US
Practice Address - Phone:860-443-4148
Practice Address - Fax:860-442-3805
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029712207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001297127Medicaid
CT001297127Medicaid
160001228Medicare ID - Type Unspecified